Contact Information

Would you like appointment reminders to be sent via voice, email, or text?* (please specify which):

Voice

Email

Text

Neither

Current job/employer*

Will you be using insurance?*

Yes

No

Gross Family Income

Number of people in your family

Is there someone else responsible for the bill?

Insurance Information

Primary Insurance*

Provider Services Phone #*

Insurance ID#*

Group number

Is this an out-of-state plan?

Yes

No

Pre-authorization # and contact person

Are you covered through an MCO?

Yes

No

Amerigroup or UHC of RV?

Amerigroup

UHC of RV

Have you seen any other counselor or psychiatrist in the past 6 months?

Yes

No

What is your PCP's name?

What is your PCP's phone number?

Other Insurance Company Name:

Insured's Name*

Insured's DOB*

Insured's Employer*

Do you have secondary insurance?*

YesNo

Secondary Insurance*

Provider Services Phone #*

Insurance ID#*

Group number

Is this an out-of-state plan?

Yes

No

Pre-authorization # and contact person

Are you covered through an MCO?

Yes

No

Amerigroup or UHC of RV?

Amerigroup

UHC of RV

Have you seen any other counselor or psychiatrist in the past 6 months?

Yes

No

What is your PCP's name?

What is your PCP's phone number?

Other Insurance Company Name:

Insured's Name*

Insured's DOB*

Insured's Employer*

What issues are you seeking treatment for?

Abuse/trauma

Aggression/anger

Aging

Anxiety/nerves/worry

Asperger/Autism Spectrum

Attachment disorders/problems

Attention/concentration problems

Behavior problems/acting out

Delusions/thought problems

Dementia/memory problems

Depression

Dissociation

Eating Disorder problems

Emotion management/regulation

Family issues

Grief

Hallucinations

Hyperactivity

Identity concerns

Impulsivity/poor decisions

Intellectual/Learning Disabilities

Learning Disability/school problems

Life Transitions

Mood Swings/mania

Neurological (head injury, seizures, stroke, etc.)

Obsessions/Compulsions

Personality problems

Relationship problems

School problems

Self-injury

Suicidality

Sexual problems

Social problems

Spiritual concerns

Substance use problems

Trauma/PTSD

Unusual behaviors/statements

Work problems/fitness for duty

Other

Unsure

What type of service are you seeking?

Counseling:

Individual counseling

Group counseling

Couples counseling

Premarital counseling

Family counseling

Other Services:

Career Counseling

Parenting skills

Biofeedback

Psychological/Neuropsychological Testing

Question goes here...

Psychiatry/Medication

Spiritual direction

Please list any current psychiatric medications

Current prescriber

Are you currently receiving any counseling, or treatment with any provider?*

Yes

No

With whom and what kind?

Who referred you to our Center?

Doctor/medical professional

Another mental health provider

Friend or family member

Spiritual leader

Internet

Other

Do you have any preferences you would like us to consider when assigning a therapist (such as gender, age, religious or spiritual identity, therapeutic modality, language spoken, etc.)? Are you looking to meet with a specific counselor?

If your schedule is limited, please explain your availability in the box below. Please be aware that we will make every effort to accommodate, but that clinicians may have greater or lesser availability at certain times.